The Killer Exposed

Back when researchers first discovered the correlation between cholesterol levels and heart disease, many of us thought we'd discovered the root cause of coronary heart problems. We thought that doctors were finally in a position to intervene and save patients from a pernicious and deadly disease. Those on the front line felt on top of the world--or at least on top of the summit they had been scaling for so many years.

The researchers were wrong. How do I know? Because I was one of them. In fact, I participated in one of the original studies to determine the effects of lowering cholesterol on heart-disease risk. Over the course of the study, we met with patients periodically to review their progress.

Since that study included only male participants, I was surprised one afternoon to see a woman waiting for me. Her question was simple: "My husband's cholesterol numbers were perfect, and you told him that based on those numbers he was at low risk of heart disease. So why did he drop dead suddenly of a massive heart attack?"

As you can imagine, I was devastated, but at the time I didn't have an answer to give her. Almost 20 years have passed since that day, and I now believe that I can finally offer her--and the many others who have lost husbands and wives, fathers and mothers, sons and daughters to an unexpected heart attack--an answer to that question.

It's certainly true that the correlation between heart disease and cholesterol was a discovery of critical importance, and the standard cholesterol blood test--total cholesterol, LDL, HDL, and triglycerides--became (and remains) routine at every physical. Our mistake was in thinking that it gave us all we needed in a blood test for heart disease.

The sheer, horrifying frequency of "surprise" heart attacks was the tip-off that the cholesterol breakthrough was a false summit. For anyone not yet convinced, here's an ice-cold wake-up call: If we use the total-cholesterol test as our sole predictor of heart-disease risk, we miss eight out of 10 cases. That's a shocking percentage, and it means that--contrary to what you've heard and read--normal cholesterol results aren't necessarily reliable measures of your risk.

The good news is we now have the ability to go beyond basic cholesterol and screen for a far broader spectrum of risk factors that show up in your blood. While there are a number of these "metabolic markers," one of the most important--and deadly--is an especially small, dense form of LDL.

If you have it--and one study indicates that 50 percent of men with heart disease do have it--you're three times more likely to have coronary artery disease, even if everything else (such as your body weight and your standard-cholesterol-test results) is perfect. And, that risk doubles to six times if you have a lot of these LDL particles.

Scary? Yes. But, fortunately, we know that small LDL responds remarkably well to lifestyle changes such as diet and exercise. This means that many of those stealth heart attacks are preventable. Maybe even yours.

A Bad Pattern

If the LDL in your blood consists of predominantly small, dense LDL particles, we say that you're LDL pattern B (people whose LDL is predominantly large are called LDL pattern A).

Why is this tiny lipoprotein such a big deal? First of all, the size of these particles makes it easier for them to weasel their way into the artery walls, where they cause all kinds of damage. And the presence of small LDL also implies the presence of a truly nasty metabolic stew.

The stew includes rapid progression of partially blocked arteries; arteries that are more prone to sudden spasm; an increased number of blood fats after a meal; lousy removal of cholesterol from the blood supply; platelet stickiness that increases the likelihood of a heart attack caused by a blood clot; insulin resistance; plaque instability; and more.

You may not have all of these things if you have small LDL, but all of them are associated with it. People with small LDL are also more likely to have low HDL, or "good" cholesterol, which means that cholesterol isn't taken out of blood vessels as well and as fast as it might be. Low HDL is also associated with an increased risk of cardiovascular disease.

So these are some of the very good reasons why we worry so much about catching and treating small LDL.

The Small-LDL Paradox

There's another danger to being LDL pattern B: If you have small LDL and have heart disease, the disease will get worse twice as fast as it will in someone who doesn't have small LDL. But if you treat it, you can seriously retard the further development of the blockages and, in many cases, stop the progression of the disease more easily than a person without these small particles could.

In fact, in a small percentage of cases, you can actually cause the disease to regress. In other words, LDL-pattern-B patients have the most rapidly progressive disease, but they are also the patients who respond best to treatment.

Bad Odds, Made Worse

Still not convinced you should be tested for small LDL? Consider this: People with small LDL may also have elevated levels of the metabolic marker apo B, the combination of which may increase the risk of coronary artery disease increases by six times. Worse, the presence of small LDL, elevated apo B, and high insulin ratchets your risk up to an alarming 20 times normal.

A Happy Ending

Here's some good news: Although the size of your LDL particles is genetically linked, your risk can be modified through treatment.

In fact, we can actually convert you from a high-risk LDL pattern B to a low-risk LDL pattern A. And the treatment isn't complicated or expensive. Weight control, a diet relatively low in saturated fat and simple sugars, and an adequate amount of exercise will often do the trick. So if you have this risk factor, don't despair. Just get busy.

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